1. Psychology Formulation Based Staff Training Surehaven Hospital Dr Marie-Louise Holmes Clinical Psychologist

2. Surehaven Hospital Shaw Healthcare Opened in Drumchapel 2010
17 bed low secure psychiatric hospital
Patients detained under the Mental Health Act and requiring a secure care environment
Range of presentations, psychosis, personality difficulties, learning disabilities, brain injury
Two wards, male and female
MDT – Hospital managers, consultant psychiatrist, occupational therapist, clinical psychologist, nursing team and healthcare assistants.

3. Training Rationale
1. To empower the ward based staff in relation to the use of empathic containment of patient distress.
2. To enhance staff understanding of patient behaviour from a psychological perspective
3. To equip staff with skills necessary to support individual psychological therapeutic work
4. To capitalise on the high level of enthusiasm and dedication to patient care that existed within a newly recruited staff team
5. To provide a rich learning opportunity aimed at increasing insight and empathy rather than simply information provision

4. Forensic Psychology Matrix Guidance
Therapeutic Milieu Training
‘All front line clinical staff should be made aware of the particular difficulties of working with psychiatric in-patients with forensic needs, and the underlying reasons for challenging behaviours.’
‘They should be given training in basic psychological models and advised of the aims of the psychological interventions available with the service so that they can reinforce the skills patients learn in psychological treatment.’
‘Special attention should be given to equipping staff with the skills necessary to feel confident in supporting the emotional and mental health needs of service users.’

5. Psychological Formulation
A hypothesis about service users difficulties based on psychological principles and theories
The assumption is that this process will render even the most unusual or disturbing behaviour and experiences understandable:
‘At some level it all makes sense’ (Butler, 1998)

6. Key Elements of Training Design
Training needs analysis carried out
Particular service users difficulties considered
Psychological interventions already underway
MDT reflection on areas for development
Training made mandatory for all staff

7. Initial Topics Identified
Understanding and Responding to –
Personality Difficulties
Psychosis
Suicidal Behaviour
Self Harm
Introduction to –
Compassionate Mind Therapy for Trauma
Counselling Skills Training

8. Style of Delivery
Opportunity to model warm, empathic and containing therapeutic style
Small numbers facilitate interactive workshop dynamic rather than lecturing style
Emphasis on collaboration and eliciting existing knowledge from the audience
Safe space for non-judgemental exploration of reality of working with complex presentations

9. Content and Structure
Participants identify what they wish to gain from the day
Structure is flexible with interactive discussion tailored to needs of the particular group
Education / Theory section – interactive, elicit existing knowledge and combine with theory
Video clips or practical exercises to reinforce theoretical understanding
Case study – Participants develop basic formulation and devise intervention
Skills practice
Reflective consolidation of main learning outcomes
Feedback and further resources

10. Example Session Personality Difficulties
Aim to increase insight and empathy
Assumption that this will reduce staff counter-transference reactions

11. Personality Difficulties Training
Before session staff asked to write down words that come to mind in relation to ‘Personality Disorder’ –
Obsessional, Manipulative
Impatient
Difficult to manage, burn out
Frustration
Helpless
Heart sink
Dependent
Emotional, self harming
No reasoning, anxious, narcissistic, controlling

12. Main focus of the day –
Psychological understanding based on concept of Early Maladaptive Schemas (Young 2003)
Developmental psychology perspective firmly rooted in Attachment Theory
De-stigmatising approach
Extreme personality traits – result of genetic temperament and unmet needs arising from attachment difficulties in childhood.

13. After session participants repeated exercise –
Lonely
Abandoned
Self loathing
Treatable
Vulnerable
‘The behaviour is not about me’ (the healthcare professional)
Emotional needs unmet
‘..didn’t choose their genetics or environment..’
‘Still emotionally a child’
Difficulty communicating
Misunderstood
Clear shift in the themes being expressed

14. Compassionate Mind Therapy for Trauma
Key approach used at Surehaven in the treatment of patients with chronic interpersonal trauma histories
Mechanism of change is teaching patient to emotionally relate to self with compassion and understanding rather than self loathing and blame
This undermines process which maintains suicidal feelings and emotional attacks on the self

15. Participants engaged in experiential therapeutic exercises
Reflection on their own level of self criticism
Writing a compassionate letter to themselves
This proved useful in terms of both personal and professional development
Staff were better able to support psychological intervention using this approach by encouraging patient to use self compassion as a response to distress rather than self criticism

16. Feedback / Audit Feedback from all sessions very positive
Likert scale ratings all either agree / strongly agree –
Theory was clearly explained
Practical exercises enhanced learning experience
Delivery style tailored to meet needs of the group
Able to apply knowledge / skills in your role

17. Qualitative Feedback Staff responses indicate
Increased empathy for patient difficulties
Increased insight into psychological factors influencing presentation
Improved confidence in therapeutic relationship building
Increased confidence in responding to distress
Improved understanding of psychological interventions
Increased recognition of own skills
More realistic expectations of self and patients

18. Patient responses included –
‘Staff are better equipped to help me and speak about my problems’
‘The enthusiasm from all the staff has been great’
‘Its great that nursing staff can follow up my psychology work with me’